Case discussion: How would you treat this patient? [13 December]

This week’s case discussion features a middle-aged male (a surfer) who presents to my practice for a skin check and complains about his lips. He notes that they have been like this “for months”.

Firstly, what would you do next?

I made a clinical diagnosis of actinic cheilitis, and considered my treatment options. What are they, with pros and cons? What would you do?

case discussion

– Prof David Wilkinson

Update

I chose PDT with ALA and LED activation. I don’t have a follow-up image as he left for work overseas, but a video call before he left confirmed complete resolution.

We encourage you to participate in the case discussions and submit your own clinical images and questions, so we can all learn together.

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16 comments on “Case discussion: How would you treat this patient? [13 December]

  1. Explain the condition to the patient. Severely limit sun exposure. Regular use of a high SP lip balm, wide brimmed hat (not when surfing). Topical Rx eg. 5 FU, Imiquimod, PDT. Other Rx: cryotherapy , surgery possibly if area of SCC detected. Explain to the patient that this is a pre-malignant condition and he should have regular skin checks to determine if a cancer has developed on his lips.

  2. I agree with the above diagnosis and would give sun protection advise accordingly. However, since he has had this “for months” I would refer for a punch biopsy to rule out invasive SCC.

  3. I’ve treated a lot of surfers lip.
    Efudix three times a week for two weeks.
    Yes, you get a florid reaction but it works and beats SCC or vermillionectomy

  4. Well it’s very sensitive and painful place. So better to advise against sun exposure and use emollients regularly like Vaseline. I am not if applying Imiquimod or cryrocautery will be tolerated by the patients as both are very painful. For me I will opt to what I stated and to keep an eye. If SCC is suspected then a biopsy is needed where will refer to a plastic surgeon.

  5. The only issue with using Efudix or Imiquinod is that he is going to end up with a horrible bleeding mess of his lower lips, which he won’t thank you for and which he may therefore stop after 2 weeks.And which will make it difficult for him eating and being in public. Not to mention surfing Et cetera. I would do 4 mm punch biopsies in 2 or 3 places ascertain dysplasia. Explain the findings to the patient and then use cryotherapy; contact with the probe on the lip 35 seconds minimum to ensure the full penetration to the stratum germinatum.I would do the cryotherapy starting with the 2 lateral areas ,so as not to be completely facially disruptive ,and then with a 4 week period repeat with inner lesions.

  6. Actinic CHelitis Cryotherapy 15 second freeze thaw Review in 3 months Sun protection advice eg Zinc
    No need for path unless obvious ulceration

  7. Do a dermoscopy, exclude SCC like pattern, If appears to be actinic in pattern, i would initiate treatment with cryotherapy serial cycles over 3 weeks until healed. usually responds well. other option efudix over 10 days

  8. A great topic for discussion, thanks for raising it.
    Cryotherpay, but painful, risk of blisters, wouldn’t do all at once
    Some use Efudix on the lips, but I haven’t used it on anyone
    Vermillionectomy
    Laser ablation

    1. I would do cryotherapy in a few different sessions and give sun protection advice, cease smoking if a smoker and follow up of the treatment area in about 3 months to check response to treatment; also a full skin check

  9. I am concerned about the ulceration left of midline, ? rolled edge and I expect thick to palpation. I would feel better with a punch biopsy if the dermoscopy is not 100% reassuring. ( ? degree of dysplasia) I use Cryrotherapy but have seen 5FU used with great results. I like to take a photo, and at the least and review at 6 months if heals, Any ulcer that persists longer than 3 weeks after treatment is suspicious. I like to scare patient with photos of SCC’s of the lips.

  10. If it is actinic cheilitis without dry, rough and thick lesions with scales and white secretions, in this case it is at a neoplastic stage. I have to do shave biopsies at 2 or 3 different places and give him symptomatic treatment while waiting for the results.